ENS 41620

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v t e ENS Event
06:00 Apr 19, 2005
Title	Equipment Failed to Function as Designed
Event Description	The following information was provided by the State via facsimile: On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital. The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing. The licensee has developed, an action plan for this event based on possible causes: 1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule. 2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician. 3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education. A voluntary MedWatch form was sent in to the FDA. Wisconsin Radiation Protection Section plans on investigating this event. State Event Report ID # 24.

ENS 41620 +/-
Where
Aurora Baycare Medical Center Green Bay, Wisconsin (NRC Region 3)
License number:	009-1017-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+57.08 h2.378 days <br />0.34 weeks <br />0.0782 months <br />)
Opened:	Mike Welling 15:05 Apr 21, 2005
NRC Officer:	Chauncey Gould
Last Updated:	Apr 21, 2005
41620 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Baycare Medical Center with Agreement State
WEEKMONTHYEAR2018-07-17T05:00:00 [Table view]
[ENS list for Aurora Baycare Medical Center]

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